WQ0019908_Monitoring - 11-2021_20220328

~FORM: NDMR 10-13 NON -DISCHARGE MONITORING REPORT (NDMR) Page of
Sampling Person(s) Certified Laboratories
Name: NA Name: NA
Name: Name:
Does all monitoring data and sampling frequencies meet the requirements in Attachment A of your permit? 91 awpliant ❑hcn•Cwnptlant
If the fac{itty is non-compfiant, please explain in the space below the reason(s) the facility was not In compliance. Provlde in your explanation the dale(s) of the rton-compliance and desMbe the corrective
actfontsl taken, Attach additional shoots if necessary.
Operator In Responsible Charge (ORC) Certification Permittae Certification
ORC:�,QiAPermlttee: Holt Lake Golf & Rec. LLC DBA .!o ston Co. Country Club
Certification No.: NA 5lgning Official: C&
15 cD,
Grade: NA Phone Number. �31�' [ -7 /'r ("O Signing Official's Title:
Has the ORC changed since previous NDMR? (]Yes [fto Phone Number: J—ill �� qr �/6 Permit Patpiratlon:
f
Date
Byths stgnahao. I certify that tt, s report Is acatarata and complete to tho boat of my knckedge.
Signature Date
I eartffy, urttter penally of Law, that ft dacumenl snd aJ allachmWs ware preparrd under my dLedan or supervision to
eocordanco Wth a syetom designed to =Lm that all qualtllod pefeannel properly gathered and evaluated the Iniarmatlan
suhmilled. Based an my bqutry of the person or persons who manage tho system, br those persons dtractty responsible for
goiharhg the Information, the Wonnation submitted Is, to the best of my knowledge and belief, true, oowrate, and complato. I am
aware that there are slgr tkani penallies far su milting fatso Wormallon, tmbiding ilia pos&WRyot Pees and Empdsonmeat for
knaw:ng wwaLtans.
Mali Original and Two Copies to:
Division of Water Resources
Information Processing Unit
1617 Mail Service Center
Raleigh, North Carolina 27699-1617